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Home , Cabergoline, Ergometrine, Lactation suppression

IMMEDIATE SUPPRESSION OF

POLICY BC Women’s Hospital and Health Centre is a World Health Organization (WHO) recognized breast- feeding and ‘baby-friendly’ hospital. There are however circumstances when avoidance of is necessary and suppression of lactation is desirable.  Breastfeeding is contraindicated for born to HIV positive irrespective of maternal antiretroviral therapy and viral load. HIV positive women should be supported when using alternate feeding methods for their infants.  Women with stillbirth or second trimester termination may wish to offer their breast to the milk bank or to suppress their lactation.  Women taking medications contraindicated in breastfeeding.

Appropriate treatment should be provided to manage potential pain and engorgement in non- breastfeeding women until lactation ceases. All non-breastfeeding women should be offered pharmacological methods of .

Applicability: Care of a woman who requires immediate suppression of lactation occurs in the Acute Perinatal Program.

PROCEDURE 1.1 Immediate Suppression of Lactation after Birth  There is insufficient evidence to recommend one single form of non-pharmacological or pharmacological treatment.

. Non-pharmacologic Strategies o Avoid unnecessary breast stimulation. o Wear a firm supportive bra or top. o Apply external agents (cool cloths, ice packs, washed cabbage leaves).

. Pharmacological Strategies o Advise the woman regarding the options for analgesia (e.g., acetaminophen, NSAIDS if not contraindicated). o Advise the woman regarding the option of using for the prevention of lactation, including its role and potential side effects.

1.2 Cabergoline Summary  derivative which directly stimulates D2 receptors on pituitary lactotrophs to inhibit secretion.  Moderately protein bound (41%) with long elimination half-life (63-69 hours).  Metabolized by hydrolysis into inactive metabolites; no involvement of CYP-P450 system.

1 mg (2 x 0.5 mg tablet) orally on  Give with to improve tolerability the first postpartum day  No dose reduction required for mild or DOSAGE (may be given up to 2-3 days post- moderate hepatic or renal insufficiency partum; most effective on first postpartum day) , Fatigue, Dizziness,  Maximal hypotensive effect occurs < ADVERSE EVENTS Nausea, Orthostatic hypotension 6hrs after intake  Hypersensitivity to cabergoline or any derivative CONTRA-INDICATIONS  Hypertensive disorders in

WW.06.07O Fetal Maternal Newborn and Family Health Policy and Procedure Manual Effective Date: 27-OCT-2015 Page 1 of 2 IMMEDIATE SUPPRESSION OF LACTATION

 Postpartum and receiving anti-hypertensives  Pulmonary or cardiac fibrotic disorders  Cardiac valvulopathy

 Raynaud’s syndrome PRECAUTIONS  History of psychosis  Gastrointestinal bleeding Dopamine antagonists (e.g.,  Co-administration may reduce prolactin , ) lowering effect of cabergoline ▪ Ergot alkaloids (e.g., )  Theoretical additive toxicity with ergot alkaloids; no documented interaction DRUG INTERACTIONS documented ▪ Macrolide antibiotics (e.g.,  Pharmacokinetic study reported / Clarithromycin) increased clarithromycin levels; no documented clinical adverse effects

DOCUMENTATION Prescriber’s Orders Medication Administration Record

REFERENCES 1. Money D, Tulloch K, Boucoiran I et al. Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission. J Obstet Gynaecol Can 2014;36(8):721-51. 2. Oladapo OT et al. Treatments for suppression of lactation (review). Cochrane Database of Systemic Reviews 2009, Issue 1 3. Dostinex® Product Monograph, Kirkland, Quebec: Canada Inc. July 2013

APPENDIX

Appendix 1: Literature Summary for Lactation Suppression Treatment for Post-Partum Women (WW.06.07P)

WW.06.07O Fetal Maternal Newborn and Family Health Policy and Procedure Manual Effective Date: 27-OCT-2015 Page 2 of 2